Regional for TKA's

Started by siednarb
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siednarb

siednarb

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Just wondering what those of you in private practice do for TKA's in terms of regional - ie do you do a femoral catheter or single shot femoral nerve block. Do you supplment with a popliteal nerve block? Also what concentrations and which LA are you using? We have been single shot blocks with 0.5% ropivicaine (20 ml) just to the femoral nerve - but some of the physical therapists have been complaining that the patients can't participate in rehap on POD #1 - I've been asked to look into this so I'm curious what other institutions do for with respect to regional and TKA's. Thank you!
 
siednarb said:
Just wondering what those of you in private practice do for TKA's in terms of regional - ie do you do a femoral catheter or single shot femoral nerve block. Do you supplment with a popliteal nerve block? Also what concentrations and which LA are you using? We have been single shot blocks with 0.5% ropivicaine (20 ml) just to the femoral nerve - but some of the physical therapists have been complaining that the patients can't participate in rehap on POD #1 - I've been asked to look into this so I'm curious what other institutions do for with respect to regional and TKA's. Thank you!
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Spinal for surgery and post op continous femoral block.
 
SAB for surgery, preop femoral catheter, and either a sciatic single-shot or catheter, depending on the surgeon's preference. I find it easiest to do the femoral cath first then throw the leg up in a modified stirrup and do a Raj approach block/catheter. Good success rate, little post-op pain.

Regards,
PMMD
 
Using epidurals now. Used to do the spinal + postop fem cath combo, but those fem caths can be such a pain... Epidural's by far the easiest way to go.
 
Believe it or not, up until about a year ago, we were doing GA for almost all our knees. Now we're doing epidurals for the case, but nothing for post-op. The surgeons inject some voodoo in there (local, morphine, +/- ketorolac) which never seems to provide any analgesia.

My mom just had her TKA at a different hospital (private) and they did a fem block and a spinal, although it sounds like the fem block didn't do much.


if it were up to me, for most people, I'd probably do a spinal with duramorph. These seem to last 18 hrs or so and doesn't interfere with PT the way some of the blocks and catheters can.
 
In the real world:
Epidurals are problematic because of anticoagulation and because of hypotension.
Intrathecal morphine is problematic because you will be blamed for anything that happens to the patient in the next 24 hours.
 
Spinal plus single shot femoral nerve block only, 25 mL 0.5% Bupiv, PCA. Most do just fine. Once the block wears off they use the PCA. Oral pain meds by POD #2.
 
fem cath and single shot sciatic block done preop for post op analgesia.

LMA for surgery.
 
For TKA's we use GA plus Depodur (lyposomal epidural morphine). It is suppose to last for almost 48hrs while is usually starts to wear off nearing 40 hours but the physical therapists really speak highly of it.
 
For the spinal do a hypobaric in the lateral position and just an isobaric sitting. Also in addition to the duramorph what kind of locals are you guys using and how much? Bupivicaine vs Ropivicaine or whatever else?
 
Fem single shot (ropiv 0.5 30-40cc) with an lma. Believe it or not a couple of our surgeons don't want us to do blocks on these patients and they get straight ga.
 
SAB for just about everyone, along with an optional single shot Femoral and Sciatic. Ortho and PT hate the catheters because they like the patients up and moving first thing next morning for PT and discharge planning.
 
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